The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)

Has a history of alcohol abuse

Bathes three to four times a week

Has a history of diabetes mellitus

Becomes diaphoretic on warm days

is prescribed antidepressant

Has a history of a cerebrovascular accident CVA

Answer and Explanation

Correct Answer : A,C,D,F

A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.

B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.

C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.

D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.

E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.

F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.

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Correct Answer is ["A","B","E","F"]

Explanation

A. Functional status
Explanation: Assessing the functional status helps determine the individual's ability to perform daily activities independently. Identifying any decline in function can guide interventions to prevent future falls.

B. Medical history
Explanation: A comprehensive medical history review can reveal any pre-existing conditions, medications, or health issues that may contribute to falls. Understanding the individual's medical background is crucial for effective fall prevention strategies.

C. Financial status
Explanation: Financial status is generally not directly relevant to post-fall prevention assessments. While financial difficulties may have an impact on an individual's ability to access certain resources, it is not a primary consideration in fall prevention assessments.

D. Occupational history
Explanation: Occupational history is not a standard component of a post-fall prevention assessment. The focus should be on functional status and physical abilities rather than specific details of the individual's occupational history.

E. Physical status
Explanation: Evaluating the physical status includes assessing balance, strength, gait, and mobility. Identifying physical impairments can guide targeted interventions to address specific risk factors for falls.

F. Environment
Explanation: Assessing the environment involves identifying potential hazards in the home or care setting that could contribute to falls. Modifying the environment to enhance safety is an important aspect of fall prevention.

A. Some of the residents are wearing blankets around their shoulders to keep warm. B. It feels much warmer in the administration wing than out in the client care areas C. An ambient temperature of 62°F is unsuitable for older people because they have impaired thermoregulation D. It is not fair for older adults to have to deal with an uncomfortable environment

Correct Answer is C

Explanation

A. Some of the residents are wearing blankets around their shoulders to keep warm.

Explanation: While this indicates that some residents are taking measures to keep warm, it is more of an observation than a documentation of the overall impact of temperature on the health and well-being of all residents.

B. It feels much warmer in the administration wing than out in the client care areas.

Explanation: This statement relates to variations in temperature within the facility but does not directly address the suitability of the overall ambient temperature for the well-being of older adults.

C. An ambient temperature of 62°F is unsuitable for older people because they have impaired thermoregulation.

Explanation: Older adults often have impaired thermoregulation, making them more vulnerable to temperature extremes. A temperature of 62°F may be too cold for older adults, increasing the risk of hypothermia or discomfort. Addressing the potential impact of impaired thermoregulation on older individuals' health and well-being is crucial in maintaining a safe and comfortable environment.

D. It is not fair for older adults to have to deal with an uncomfortable environment.

Explanation: While fairness and comfort are valid considerations, the primary concern should be the potential impact of the ambient temperature on the health and well-being of older adults, especially considering their impaired thermoregulation.

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The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

Which of the following assessments should be included in a post fall prevention assessment of an older adult? (Select all that apply.)

Correct Answer is ["A","B","E","F"]

Explanation

The overall temperature in the gerontological unit is 62°F during the evening shift. In documenting this concern to the administration, which factor is the most important for the health and well-being of older adults?

Correct Answer is C

Explanation

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